Real choice is about much more than location - it can cover interventions and clinicians, too, as Jennifer Taylor explains
Patient choice should be about choice of intervention, not provider, says Baroness Julia Neuberger, who speaks on health for the Liberal Democrats in the House of Lords.
'I'm very worried about always saying that choice of provider is key,' she says. 'Patient choice should be about choice of interventions and in some circumstances choice of provider, but by no means always.'
This is the Liberal Democrat stance on choice, and Baroness Neuberger argues that not only is choice of provider destabilising, but it caters to the articulate middle classes and fails to meet the needs of patients with long-term conditions.
Many patients, particularly older people with chronic conditions, do not want to change hospitals and doctors. The argument is that they need to build relationships with their doctor and other healthcare professionals, have a service they trust and be given choice of intervention.
'There are a lot of conditions which have a whole range of treatments all supported by evidence which could and should be offered to patients,' says Baroness Neuberger.
There are some provisos, she says. A reasonable NHS should not offer treatments that have no evidence of effectiveness, although treatments that have not been assessed for effectiveness should be an option until they have been ruled out.
Access is another important aspect of choice, says Baroness Neuberger, and should be made easier in a variety of ways, keeping in mind the trade-offs between cost and convenient access.
Of course, there will be some circumstances in which patients will want to choose their provider, such as using a specialist centre, and for that they will need to balance the trade-offs between distance, inconvenience and quality.
In general, however, Baroness Neuberger says we should be able to say that within the NHS all treatment will be of a good standard. 'I'd much prefer to see a system where there is no provision of poor quality care in the NHS,' she explains. 'If it's bad, you close it down.'
A wider definition of choice
Choice of intervention is also essential for Diabetes UK chief executive Douglas Smallwood. 'What's really important is that when we look at long-term conditions, choice is not about whether you receive treatment in hospital A or hospital B, or doctor's surgery A or doctor's surgery B, it's about making choices on my care plan,' he says.
'We believe people should make those choices, that they will be healthier and their outcomes will be better if they understand how to manage their diabetes.'
This understanding comes from having high-quality information about medication and lifestyle. Mr Smallwood argues that part of a patient's prescription should be information. So when GPs prescribe medication for a new patient with diabetes, for example, they would also prescribe Diabetes UK's Diabetes for Beginnersand both would be picked up from the chemist.
Choices should be linked to each stage of the care pathway, he says. One step towards that will be to build choice into the 'year of care' described in the Our Health, Our Care, Our Saywhite paper in which patients will agree with their clinician what their year's care will look like.
The national diabetes support team is currently articulating the standards for a year of care in diabetes and what patients should experience.
'Let's build choice within that and develop it into a lifetime protocol,' says Mr Smallwood. This could include type of medication, whether prescriptions are collected from the pharmacy or doctor's surgery, and how often the patient sees their consultant.
He adds that different sections of the community will need different choices, depending on age and co-morbidities.
Dr Tom Coffey, GP and chair of the New Health Network, agrees that patients should automatically be given information. He says there should be standardised patient information leaflets available in a national patient information library which both GPs and patients could access.
For a patient with a new diagnosis of diabetes, the GP could print out standardised information for the patient to take away, which would help them when deciding which treatments to choose.
He warns, though, that the types of treatment from which patients will be able to choose are set to change. 'We will be restricting treatment to things which have evidence to say it works,' says Dr Coffey. 'So we'll no longer be doing varicose veins or cosmetic surgery.'
The development of practice-based commissioning also now means there is a vehicle for GPs to deliver evidence-based medicine, linking referrals to treatments they know will have an impact. 'It will reduce patient choice, but it will mean more effective use of the NHS pound,' says Dr Coffey.
But he adds: 'Once we've got effective treatments, choice should be as wide as possible. I would offer choice of wherever you want to go.'
However, GPs may restrict choice through practice-based commissioning and choose and book because they will want patients to choose community-based treatments, as opposed to more expensive hospital-based treatments. There may also be an inclination to encourage patients to choose the services being set up by GPs and practice-based commissioning consortia.
'Although practice-based commissioning will produce good demand management and balancing financial books, it might have the other effect where patients will be pushed down a path of treatment, which one would hope will be as good, but real open choice won't be as open as it could be,' warns Dr Coffey.
'Practice-based commissioning and choose and book put a lot of power back into the influence the GP has over the referral side, so patient choice on where they go for treatments [could be affected].'
Information to inform choice
When it comes to choosing where to go for treatment, information on doctors is one aspect patients will consider. General Medical Council president Professor Sir Graeme Catto says more information about doctors should be provided, and in a clear, accessible format.
The GMC, as the sole keeper of the register of all doctors in the UK, is well placed to do that. 'The GMC is often portrayed as a very austere, distant organisation,' he says. 'But if we're going to have greater choice in the future, the GMC ought to be part of that information-providing arrangement.
'We get thousands of hits a day on our website, but I suspect that when people get there, they don't find the information terribly helpful.'
Sir Graeme's vision is that this information would be provided in three tiers. First, the GMC register, which includes the doctor's primary qualification, disciplinary problems, and whether or not they are on the specialist or GP register.
Second, colleges could provide accreditation information. Finally, doctors could provide information on what they are doing in practice and where, verified by a chief executive or medical director.
Information provided by doctors will have to be part of a flexible system, says Sir Graeme. 'What we don't want is a bureaucratic system where every time a doctor changes job or moves to another hospital they've got to seek permission from the GMC,' he says. 'That information needs to be left more to the discretion of the doctor, recognising that if it's on our website we'll be checking up on it.'
The new system will require a change in attitude. 'Most information about doctors in this country is perceived as negative,' says Sir Graeme. 'We need to shift the emphasis and allow doctors to display their wares.'